83-1189 - Laserfiche WebLink

Home Browse Search

! APPLICATION FOR PERMIT SAN 3OAQU;N LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 PERMIT EXPIRES I YEAR FROM [DATE ISSUED DATE ISSUED . 3 (Complete in Triplicate) Application�'is hereby made to the San-Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No 549 for sewage or No. 1862 for well/pump and the Rules an� R gulation of e S n Joaa,u}n Local Health District, Job Address _-Stehd'viiimr Name Owner's Name Address Phone r Contractor's Name icense No. Phone Q TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION _ PUMP INSTALLATION SYSTEM REPAIR OTHER +U } DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSA FLD. PROP, LINE W FOUNDATION AGRICULTURE WELL _ RWL LL PITS/SUMPS r _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial — U Open Bottom EJ Manteca Dia. of Well Excavation, L} Domestic/Private ❑ Gravel Pack- E] Tracy Dia, of Well Casing .� 1-71 Public Other ,Delta —1 Irrigation Type of Casing", Approx, Eastern F-1CathodicProtection Depth q Specifications Geophysical Depth of Grout Seal U Other Type of Grout ` z Surface Seal Installed by. Repair Work Done EJ_ Type of Pump t H.P, State Work Done Well Destruction U Well Diameter _ Sealing Material (top 501) U1 c Depth Filler Material (Below 501) -~ TYPE OF SEPTIC WORK: ' NEW INSTALLATIVON ❑ REPAIR/ADDITION U (Ne septic tank or seepage pit permitted if public sewer is Installation -wi'll serve: Ry�sidence _ Commercial Other available within 200 feet.) Number of living units: K Number of bedrooms Lot size ' r /� Character of'soil to a depth of 3 feet: Water table depth v ' SEPTIC TANK ., Type/Mfg Capacity No, Compartments PKG. TREATMENT PLT. Type/Mfg ; Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: well Foundation Property Line DESTRUCTION 1 1 LEACH LNG-LIKE No. & Length of lines Total length/size , FILTER Distance to nearest: Well Foundation Property Line SEEPAGE PITS ^ Depth Size Number. SUMPS ' �� Distance to nearest: Well Foundation Property Line DISPOSAL PONDS I hereby certify that I have prepared this application and that the work will -be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workmant compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work far which this permit is issued, I shall employ persons subject to workman's compensation laws of California." i The applicant - 1 foe7all re r d inspectionomplete drawing on reverse side. z. Signed X Title: Date: 0 DEPRRTM NT US NLY � ' Application Accepted by Area 09 Stk466-6781 Additional Comments: y Lodi 369-3621 69,! Pit or Grout Inspection by Date dL Manteca 823-7104 Final Inspection by Date Tracy 835-6385 j Applicant - Return all copies to:, Environmental Health P it/Services 1601 E. Hazelton Ave:,�P..O. Box 2009, 5tk., CA 95201 FEE O BASE AMOUNT DUE AMOUNT REMITTED RECEIVED 8Y DATE PERMIT N0. J INF _ fG 2 ,, - EH 13-24 REV. 10/82 10/82 500 � 14-26